Who you are:
You are an F2 in Vascular Surgery.Who the patient is:
Mrs. Sarah Khan, a 60 year old woman. Other information you have: She has undergone an Aorta-femoral bypass graft in her lower limb due to vascular insufficiency that caused calf pain. She was shifted to the recovery room, after the operation. Your nurse colleague noticed that she was bleeding heavily into the drain, a few hours after the operation. She was given six units of blood products. Your colleagues all scrubbed in to the theatre. She was taken to the theatre for re-exploration. Her husband has come to the hospital to see his wife.What you must do:
Talk to her husband and explain what has happened and address his concerns.Special Note:
There was no error in surgery. This is a known complication of the surgery. Consent from Mrs. Khan has been taken to talk to her husband.
Patient information: (The positive findings for candidates to simulate)
- You are Mr Khan, 66-year-old man, husband of Mrs Sarah Khan.
- You have come to the hospital to see your wife.
- Your wife had undergone aorta femoral bypass surgery because she had some circulation problem in her legs.
- You don’t know she has suffered a bleed during the procedure.
- You feel like the doctors have made mistakes.
- You have two kids who live in Australia.
Concerns:
- You have given 6 units of blood, Is that serious?
- If doctor says it’s a complication, ask how often people develop complications like this?
- How long will the operation last?
- Why did you do the surgery in the first place if there was a risk of complications?
- I think you made a mistake?
- Is she going to die?
- Should I call my kids and tell them their mother is dying?
Always remember about BBN stations:
- Always take HX about what happened?
- Always assess knowledge about what they know, so you avoid telling them things they already know, whilst patient’s relatives are devastated and want news of their loved one.
- Always ask about support system.
- Who is here with you now? Who do you live with? Do you have any family living near to support you?
- Then, break the bad news. (2 warning shots + bad news)
- Acknowledge the emotion and give support.
- Address the concerns accordingly.
D: Hello I am Dr (name), I am one of the junior doctors here, are you the husband of Mrs. Khan?
P: Yes doctor.
D: Can you confirm for me your wife’s name and age?
P: Sara Khan, 60 years old.
D: Thank you, I am here to update you regarding your wife’s condition. But before that I want to know how much you know about her condition. (Assess knowledge of her husband about her condition.)
P: She had a problem with blood flow in her legs for which doctors had decided to perform surgery and she underwent the surgery this morning.
D: Yes, your wife had surgery this morning. Has anyone explained anything to you regarding the surgery?
(Always ask if anyone has explained before you)
P: Yes/No
D: The operation is called Aortobifemoral bypass. As you said she had a problem with blood flow in her legs and this bypass surgery is done to redirect blood around narrowed or blocked blood vessels in your belly or groin. The surgery is done to increase blood flow to the legs.
P1 focused hx about dx (V. Focused, don’t waste time asking too many questions as your task is not making dx)
D: Is it okay if I ask you a few more questions? What made her come for surgery in the first place?
P: She had calf pain and later a doctor explained it was due to vascular insufficiency.
Focused hx about bleeding (Bleeding is current complaint)
D: Has she ever mentioned to you about having bleeding from anywhere?
(Gum bleed/ nosebleed/ urine/back passage?
P2 past hx
D: Has this ever happened before?
P: Yes/No
P3 maftosa + desa
D: Does she have any medical condition? Any bleeding disorders? Any medications like blood thinners? Allergy? Any family hx of similar condition or any bleeding disorder?
D: Does she have any hx of smoking or alcohol?
P: Yes/No
D: Has anyone spoken to you about your wife’s current condition? (Assess knowledge)
P: No, I just know that she had an operation this morning. I came to see her but she was not in the recovery room.
Breaking the bad news into layers.
D: Okay, before I discuss your wife’s current condition with you, do you want me to call anyone else here at the moment to support you? (Ask support system)
P: Yes/No
D: Have you and you wife been told about the possible complications of the surgery?
P: Yes/No
D: Alright, so what happened is she had an operation this morning. The operation went well and she was doing fine after the surgery in the recovery room. Then something happened that we didn’t expect. PAUSE 1st layer
P: What happened?
D: In the recovery room, unfortunately there was a complication.
PAUSE 2nd layer
P: What do you mean by complication?
Break the news
D: The surgery went well but in the recovery room she started to bleed severely in her drain tube.
P: What? Bleeding? (They will react in different ways- If pt. cries, let them)
DON’T INTERRUPT
Offer tissue or a glass of water, acknowledge it, EVE protocol
D: I can imagine how worried you must be right now. Anyone in your shoes would react the same way.
P: What are you going to do for her?
D: We have given her six units of blood to make up for the loss.
P: What? 6 units? Isn’t it too much? Is her condition serious?
D: It is quite a lot of blood, but we need to compensate for the loss of blood and you wife is in a serious condition. Now we have taken her back to theatre immediately to stop the bleeding.
P: Will she be okay doctor? Is she going to die?
D: It is difficult to say but we will do our best to help her. At the moment, she’s in the operating room. The surgeons are trying best to stop the bleeding. We hope that they’ll be able to stop the bleeding and she’ll recover from it. I can also assure you that she is in good hands and we are trying our best. (You can do nothing but reassure)
P: Have you guys done a mistake during the surgery?
D: Not at all, I’m afraid this is one of the complications of this surgery.
P: How can she lose so much blood? I am sure something might have gone wrong?
D: I can assure you that the surgery was uneventful, which is a good thing. This is one of the complications of this surgery.
P: I wasn’t aware of this. No one had told me about it.
D: Usually we explain the procedure and all the possible complications to the patient and then take their consent. And I am sure that your wife was aware of all of it before going for the procedure.
Management (Explain the procedure/ Complications/ Advice/ Safety net)
P: What is the exact cause? How could this happen to my wife? (If they give you a paper and pen, draw and show the patient’s relative for better understanding, below there’s a picture)
D: Let me explain about the nature of this operation to you. In this operation we insert an artificial vessel between the main artery in the tummy (aorta) and two main arteries in both groins (femoral arteries) that supply blood to the legs. This involves major blood vessels and is major surgery and that’s why there is always a risk of complication. Now you can imagine why there is a chance of bleeding after this operation. (Explain clearly what and how this might have happened).
P: Why did you do the operation if you knew there would be complications?
D: Your wife needed an operation because she had problems with circulation in her leg. If she hadn’t had the surgery, there could be severe complications anyway like maybe even losing her leg. The aim of this operation was to improve the blood supply to her legs and to relieve her symptoms. In her case the advantages outweighed the disadvantages and that’s why she went for it.
(To tackle this kind of question always say benefit over risk.)
P: How often do these complications happen in this hospital?
D: It’s a very unfortunate situation that your wife had it. I assure you that this is a very rare complication occurring.
P: What is the success rate of this operation?
D: It differs from patient to patient. It depends on their age, general fitness and whether they have any medical problems. Unfortunately, your wife has developed one of the serious complications of this operation, which makes it difficult to say what will happen exactly.
P: Doctor, shall I call my children to come?
D: I think you can call to inform them. Your wife’s condition is quite serious so it’s better that your children know about it so if they want to visit, they can visit her and also support you.
P: How long will the operation last?
D: I’m not sure but we will try to control the bleeding as soon as we can. It should last a few hours at least. However, I will be updating you at regular intervals.
P: Doctor, are there any other complications?
D: Another complication could be infection at the site of operation. To prevent this happening she has been given antibiotics during the operation.
Also blockage of the bypass graft, this is a specific complication of this operation where the blood clots within the bypass graft causing it to block.
Limb loss (amputation) happens sometimes when the bypass blocks and the circulation cannot be restored. The circulation to the foot may be so badly affected that amputation is then required.
Chest infections can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.
Occasionally the bowel is slow to start working again, this requires patience and fluids will be provided in a drip until your bowels get back to normal.
Advice:
- She needs to have rest more than usual. After that she can gradually return to her normal activities.
- She should not put too much strain on her operative wound.
- She can gradually increase the amount of exercise and increasing the distance that she walks.
- She should keep the wound area clean by daily bath or shower and dry the area gently with a clean towel.
Safety netting:
If she has redness or discharge from her wound, please seek advice from her GP. If she develops sudden pain or numbness in her leg, which doesn’t get better within a few hours, please contact the hospital immediately. If she experiences any pain or swelling in her calves or any shortness of breath and chest pain, please immediately come to the A&E
(Whenever they give you a paper and pen, draw picture for them for better understanding.)